The nurse is caring for an African American client with disseminated intravascular coagulation

4.

Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing (Option 4).

(Option 1) A BMI of 25-29.9 kg/m2 indicates that the client is overweight. A sedentary lifestyle often leads to elevated BMI and also correlates with decreased bone density, which places the client at risk for fractures. However, neither sedentary lifestyle nor elevated BMI directly affects bone healing.

(Option 2) Osteoporosis (low bone density) increases the risk of fractures and delays bone healing. Although a family history does increase the risk of osteoporosis, the family history itself would not directly hinder bone healing as this client has not been diagnosed with osteoporosis.

(Option 3) Heavy alcohol use is associated with inadequate nutrition and can decrease osteoblastic activity (ie, bone formation). However, a single serving of alcohol (ie, 12 oz of beer, 5 oz of wine, 1.5 oz of liquor) per day is considered moderate usage and is not a risk factor for delayed healing.

3.

During mass casualty events, the goal is to do the greatest good for the greatest number of people. Clients are triaged using various systems (eg, Simple Triage and Rapid Transport/Treatment [START]; Sort, Assess, Life-saving interventions, Treatment/Transport [SALT]) and placed into 4 categories:

Immediate (red tag): Life-threatening injuries with good prognoses once treated (eg, airway obstruction, open fractures, second- or third-degree burns covering 15%-40% body surface area)
Delayed (yellow tag): Injuries requiring treatment within hours (eg, stable abdominal wounds, soft tissue injuries)
Minimal (green tag): Injuries requiring treatment within a few days (eg, minor burns or fractures, small lacerations)
Expectant (black tag): Extensive injuries, poor prognosis regardless of treatment
Immediate medical care of the client with an open fracture would likely result in a good prognosis (Option 3).

(Option 1) Delayed treatment is appropriate for the client with partial-thickness burns to a small portion of the body (eg, hands).

(Option 2) Depending on its size and depth, a laceration would require minimal or delayed treatment.

(Option 4) A large, open head wound with a Glasgow Coma Scale score of 3 has a poor prognosis regardless of treatment; death is expected.

1, 3, 4.

The nurse promotes client safety by implementing fall risk precautions. Standard fall risk precautions (eg, bed in lowest position, call light within reach) are appropriate for all clients. A client with multiple fall risk factors (eg, altered mental status, advanced age) has an increased risk for falls and requires additional precautions. The nurse should activate the bed alarm, place the client in a room close to the nurses' station, and place a bedside commode next to the bed.

(Option 2) Keeping the lights dim increases the risk for falls, particularly when the client is in an unfamiliar environment. A well-lit room promotes orientation and helps the client avoid obstacles during ambulation.

(Option 5) Restraints increase agitation and are associated with serious complications (eg, impaired perfusion and skin integrity). Restraints are indicated only if less restrictive measures fail to keep the client safe. The nurse should first consider alternatives such as family involvement or supervision by a trained staff sitter.

3.

Colostomies may be performed on any part of the colon (ascending, transverse, descending, sigmoid). Stool becomes more solid as it passes through the colon, so stool drainage characteristics vary with location of the ostomy. Ascending colostomies produce semiliquid stool.

Stool is contained in an ostomy appliance bag secured to the skin. The appliance opening is cut to fit closely around the stoma. If the appliance does not fit well, liquid stool may leak onto the peristomal skin, and skin irritation occurs due to the digestive enzymes in stool. Peristomal skin irritation may also occur if the ostomy appliance is removed and changed too frequently. The appliance should be changed every 5-10 days (Option 3).

(Option 1) The semiliquid consistency of stool from an ascending colostomy results in increased fluid loss. The client is encouraged to drink plenty of fluids to prevent dehydration.

(Option 2) The client with a colostomy has few dietary restrictions, but the client may be encouraged to decrease intake of odorous and gas-forming foods (eg, beans, onions, broccoli).

(Option 4) The ostomy bag is emptied when it becomes one-third full. Leaking and skin irritation may occur if the appliance becomes too heavy and pulls away from the skin.

3.

The best way for health care workers to protect themselves against possible HIV infection is to consistently follow standard (universal) precautions with all clients, regardless of HIV status. HIV is spread when nonintact skin comes into contact with infected blood, breast milk, semen, and vaginal secretions. No extra precautions are needed for routine care of clients with HIV as the virus is not spread through casual contact, droplets, or aerosolized particles. Some experienced nurses hold to the common misconception that "double-gloving" reduces the risk of contracting HIV. Appropriate use of a single pair of clean gloves provides a barrier between the nurse's hands and the client's blood and body fluids (Option 3).

(Option 1) In compliance with standard precautions, situations in which blood or body fluids may splash or be sprayed (eg, suctioning, irrigation) require additional personal protective equipment (eg, face shield, gown) as necessary.

(Option 2) Washing hands with soap and water is required to remove Clostridium difficile spores; hand hygiene with foam or gel alone is ineffective.

(Option 4) An N95 respirator is worn when the client has an illness that can be aerosolized and spread through the air (eg, tuberculosis, varicella-zoster).

2, 3, 4, 5

Pediculosis pubis (ie, "crabs") is an infestation of pubic lice. Pubic lice are most often passed via sexual contact and feed on human blood for nourishment. Clients with pubic lice have intense itching in the affected area. The nits (ie, lice eggs) are attached to hair shafts and appear as yellow-white ovals. Pubic lice may also infest eyelashes, facial hair, and body hair (eg, chest, axilla).

Clients with pubic lice should be given the following instructions:

Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5)
After treatment, remove nits with a fine-toothed nit comb, fingernails, or tweezers (Option 2)
Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4)
Sexual partners should also receive pubic lice treatment (Option 3)
(Option 1) Pubic lice may be passed through close contact and sharing of linens. All household members are at risk for developing a pubic lice infestation and should be screened.

1, 2, 4, 5.

Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). Hospitalized clients tend to have multiple risk factors for VTE, including venous stasis from prolonged immobility and endothelial damage from surgeries or IV catheter placement.

VTE prophylaxis should be implemented in all hospitalized clients. Measures include:

Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1)
Application of compression devices or antiembolism stockings to limit venous stasis (Option 2)
Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4)
Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5)
(Option 3) Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees.

4.

Arteriovenous (AV) graft placement involves surgical connection of an artery and a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection of an AV graft may cause thrombosis, graft failure, or systemic infection. Fever in a postoperative client may indicate infection of the graft site, which warrants immediate notification of the health care provider (HCP); this client may require antibiotics and surgical removal of the graft (Option 4).

(Option 1) A small amount of rectal bleeding and abdominal cramping is expected following a colonoscopy as the bowel contracts to expel the air inserted during the procedure. Following a colonoscopy, clients should notify the HCP of severe abdominal pain, distension, and excessive bleeding, which may indicate bowel perforation.

(Option 2) Following surgery, constipation can occur due to decreased ambulation and narcotic pain medications. The client may require a stool softener to reduce straining.

(Option 3) Anesthesia and opioid analgesics may cause postoperative urinary retention for up to 3 days following surgeries, especially abdominal or pelvic surgeries. This client should be instructed on measures to aid voiding (eg, standing) and may need to come to the clinic for bladder ultrasound or straight catheterization.

2.

A pregnant nurse does not have a high risk for contracting methicillin-resistant Staphylococcus aureus (MRSA) if appropriate infection precautions are used (Option 2). The nurse should carefully follow contact precautions, including wearing gloves and gown and performing strict hand hygiene. Even if the pregnant nurse were to contract MRSA, there are few known harmful effects to the fetus.

TORCH infections (Toxoplasmosis, Other [parvovirus B19/varicella-zoster virus], Rubella, Cytomegalovirus, Herpes simplex virus) can cause fetal abnormalities, and clients with these infections should not be assigned to pregnant health care workers.

(Option 1) Clients receiving brachytherapy have radioactive implants placed in a body cavity. To safely care for these clients, nurses limit/cluster client time and keep a distance of at least 6 ft (1.8 m) unless wearing lead shielding for direct care. Pregnant health care workers should not care for these clients if possible as fetal radiation exposure is teratogenic.

(Option 3) Herpes zoster (ie, shingles, varicella-zoster virus infection) is a TORCH infection, and pregnant health care workers should avoid caring for these clients.

(Option 4) Zika virus may be transmitted through mosquito bites, infected body fluids, and sexual contact. Using standard precautions should provide protection; however, because Zika is known to cause birth defects, pregnant health care workers should not care for a client exposed to it if at all possible.

1, 2, 4, 5.

Respiratory syncytial virus (RSV) is a common cause of respiratory tract infection and bronchiolitis in infants and children, occurring primarily during the winter. It affects the ciliated cells of the respiratory tract, causing bronchiolar swelling and excessive mucus production. RSV in infants causes rhinorrhea, fever, cough, lethargy, irritability, and poor feeding. Severe RSV infection also causes tachypnea, dyspnea, and poor air exchange. Interventions are supportive, including:

Providing supplemental oxygen and suctioning to support oxygen exchange and clear the airway (Option 5)
Elevating the head of the bed to improve diaphragmatic expansion and promote secretion clearance (Option 3)
Administering antipyretics to reduce fever and provide comfort (Option 1)
Initiating IV fluids to correct dehydration due to fever, tachypnea, or poor oral intake (Option 2)
RSV is transmitted via direct contact with respiratory secretions. Contact isolation is required, and droplet precautions are added if within 3 ft (0.91 m) of the client, depending on facility policy (Option 4).

Palivizumab (Synagis), a monoclonal antibody, is administered intramuscularly once monthly during the winter and spring to prevent RSV in children at high risk for contracting the infection (eg, prematurity, chronic lung disease).

2.

IV antibiotics are necessary for treating osteomyelitis (infection of the bone), and without them, the client is at risk for potentially life-threatening complications (eg, sepsis). Parental refusal of necessary medication for a minor creates an ethical dilemma. The nurse's first response should be assessment of a parental knowledge deficit regarding the client's condition. The nurse should ask open-ended questions, allowing the parent to demonstrate knowledge. With education and proper understanding of the condition, the parent may consent to the necessary treatment (Option 2).

(Option 1) Asking about beliefs regarding medications in general may help in developing a teaching plan. However, it is more important to educate the parent about this child's specific and immediate need for antibiotics.

(Option 3) Preferred healing practices are an important aspect of spiritual assessment; however, the priorities are to obtain parental consent for and initiate necessary treatment. Spiritual and cultural elements may be appropriate to include after physical needs (eg, IV antibiotics) are met.

(Option 4) Although true, this statement is inflammatory and would likely cause the situation to deteriorate, possibly leading to total refusal of care by the parent. It is most effective and important to respectfully assess parental knowledge and educate parents to obtain consent.

4.

A PRN (ie, as needed) medication prescription must state the name, dose, route, and purpose of the medication (eg, pain, nausea, sleep) and the time interval between doses. The nurse should administer a PRN medication for its prescribed purpose only. If the client requires medication for a different purpose, the nurse should contact the health care provider (HCP) to either clarify the current prescription or request a new prescription. If a client requests a sleep aid and does not have a prescription for sleep medication, the nurse should contact the HCP to request a prescription (Option 4).

(Option 1) If diphenhydramine (Benadryl) is prescribed every 8 hours PRN and the previous dose was at 11:00 AM, it would be appropriate to administer a dose at 9:00 PM; however, diphenhydramine that is prescribed for itching may be administered only for itching.

(Option 2) Lorazepam that is prescribed for anxiety may be administered only for anxiety.

(Option 3) Informing a client that there is no prescribed medication that can be administered for sleep does not resolve a client's request for help with sleep. The nurse should implement actions to address the client's difficulty sleeping.

2.

Dabigatran (Pradaxa) is a thrombin inhibitor anticoagulant often prescribed to prevent thrombotic events in clients with atrial fibrillation, pulmonary embolism, and deep vein thrombosis. Clients taking dabigatran are at increased risk for bleeding and hemorrhage. Clients with signs of abnormal bleeding (eg, bruising; blood in the urine, sputum, vomitus, or stool; epistaxis; heavy menstrual bleeding [menorrhagia]) should be prioritized as prompt intervention and treatment may be required.

(Option 1) Missing a dose of phenytoin (Dilantin), an antiseizure medication, could precipitate seizure activity. The client should be instructed to take the medication as prescribed with a small sip of water; however, this client does not take priority over one with active bleeding.

(Option 3) Gastrointestinal upset is a common side effect of many antibiotics, including metronidazole (Flagyl). Abdominal discomfort may be relieved by taking the medication with food or a glass of milk.

(Option 4) This client requires a refill of insulin to prevent hyperglycemic episodes but is not a priority over a client with active bleeding. Glargine is long-acting insulin that works for 24 hours.

1, 3, 4.

Human papillomavirus (HPV) is a common sexually transmitted infection (STI) that is often asymptomatic and may resolve spontaneously in young, healthy people. However, certain HPV strains can persist, resulting in genital warts. Genital warts can be treated (eg, topical podophyllin, cryotherapy, laser surgery) but may recur at any time (Option 1). High-risk HPV strains (types 16 and 18) increase risk of cervical, oral, and genital cancers (Option 4).

The HPV vaccine helps prevent HPV infection and is most effective if taken before becoming sexually active. However, current guidelines suggest that even teens and young adults (age ≤26) who have already become sexually active may benefit from HPV vaccination (Option 3).

(Option 2) The majority of clinical organizations recommend that cervical cancer screening (Pap testing) be initiated at age 21, regardless of sexual history. In women age <21, HPV infection rarely progresses to malignancy. Overdiagnosis and treatment of potentially benign HPV infections can lead to negative reproductive outcomes in the future (eg, pregnancy loss, preterm birth).

(Option 5) Barrier methods (eg, condoms) can reduce the risk of HPV transmission. However, abstinence is the only definitive way to eliminate the risk of contracting STIs.